Introduction by Croakey: The COVID-19 pandemic has disrupted health and healthcare in many ways. One important issue is developing a better understanding of its impacts upon Aboriginal and Torres Strait Islander peoples’ experiences of healthcare.
An important indicator of the quality and cultural safety of healthcare is whether Aboriginal and Torres Strait Islander people feel safe to remain in a service to receive healthcare, or whether they leave before healthcare is delivered or completed.
According to data recently reviewed by the Australian Commission on Safety and Healthcare, there are some grounds for concern that the pandemic has been associated with an increase or, at the very least, no improvement in leave events.
The Commission has told Croakey that it is working with the states and territories, all of which have processes in place for reducing leave events relating to Aboriginal and Torres Strait Islander peoples.
Its current focus is on “developing measurable indicators that can be applied nationally to provide consistent definitions, so that leave events can be monitored nationally,” the Commission told Croakey in a statement.
Another important question is how the pandemic has affected Aboriginal and Torres Strait Islander peoples’ access to care, given widespread reports of service closures, workforce shortages and systems under grave pressure.
Meanwhile, Dr Julieann Coombes and Keziah Bennett-Brook, researchers from the George Institute who conducted a systematic review informing national policy on leave events, suggest below that the issue deserves far more attention from policymakers, health services and providers, through efforts to address racism and improve cultural safety at all levels of the system.
Julieann Coombes and Keziah Bennett-Brook write:
Aboriginal and Torres Strait Islander people have an inherent right to receive culturally safe and quality healthcare. By better understanding why Aboriginal and Torres Strait Islander patients leave health services in higher numbers, health organisations can be better informed on how to improve healthcare services for Aboriginal and Torres Strait Islander patients.
Leave events delay people from receiving the correct medical treatment and are associated with increased readmissions. This effects ongoing medical care associated with increased morbidity and mortality for Aboriginal and Torres Strait Islander people.
A recent review looking into leave events from health services found that Aboriginal and Torres Strait Islander people are at a higher risk of leave events than other Australians. A leave event is broadly understood as an instance of a person leaving a health service prior to being seen by a health professional or has left against medical advice.
The review highlighted that it is especially important to understand that for Aboriginal and Torres Strait Islander peoples, leave events can be due to ongoing impacts from colonisation, including systemic racism within the healthcare system and issues surrounding trust and power, which other Australians broadly do not experience.
Dr Coombes, lead author on the review says, “Leave events disproportionally impact Aboriginal and Torres Strait Islander people and are not interpreted by health professionals as an indirect measure of patient dissatisfaction or racism.”
“There are very real experiences of power imbalances between Aboriginal and Torres Strait Islander people and healthcare providers. Healthcare providers need to understand that experiences of shame and disempowerment, fear of child removal, cultural misunderstandings and stereotyping must be considered within the patient and clinician relationship.”
Health service organisation policies have also been predominantly developed within a western framework that continues to reinforce power imbalances that do not take account of Aboriginal and Torres Strait Islander people and culture.
A change in service policies to balance these inequitable power structures is urgently needed and genuine engagement of Aboriginal and Torres Strait Islander communities is paramount to improve the policy structures that support change.
The United Nations Declaration on the Rights of Indigenous Peoples clearly states that First Nations people globally have the right to best practice healthcare and access to health services free from discrimination.
Within Australia, The National Aboriginal and Torres Strait Islander Health Plan 2013-2023 has a vision that the Australian health system is free of racism and inequality, which the review found were key drivers of higher leave events among Aboriginal and Torres Strait Islander patients. The National Plan also states that all Aboriginal and Torres Strait Islander people should have access to effective, high quality, appropriate and affordable health services.
While attempts have been made to understand the causes of leave events, most current research efforts are focused on studies that lack an exploration of experiences from the perspective of Aboriginal and Torres Strait Islander patients. The review highlighted the need for effective cultural capability training among health professionals and culturally appropriate holistic models of healthcare to be embedded into everyday practice.
There are various terms that are currently used within the Australian healthcare system to document leave events. These terms are often framed as if patients have a choice of whether to stay or leave, rather than understanding the broader issues that impact upon whether a patient receives the care they need.
Although these terms are widely used, they can be stigmatising to Aboriginal and Torres Strait Islander people who may leave a health service due to factors that are currently not understood or acknowledged by the health system. There are a variety of factors associated with leave events including but not limited to loneliness, waiting too long, experiences of racism, distrust of the health system, a lack of culturally safe services, miscommunication, remoteness of community, family and cultural obligations.
The Aboriginal Health Policy Directorate 2018, Department of Health WA found a number of preventions to reduce ‘leave events’. One was the need for health systems to be approachable through effective cultural safety, including cultural training of hospital staff on connection to country, kinship and family obligations. For this to be effective, training must be mandatory and ongoing rather than being just a ‘tick a box’ exercise. Cultural training models need to be developed for individual settings according to local communities’ priorities.
Aboriginal and Torres Strait Islander community-controlled health services need to be involved in developing resource information about hospital processes and what patients can expect when they attend the healthcare service.
Healthcare services must establish partnerships with Aboriginal and Torres Strait Islander community controlled health services to improve coordination and continuity of care which supports two-way communication between Aboriginal and Torres Strait Islander community-controlled health services and mainstream healthcare services.
Co-author on the paper Keziah Bennett-Brook says, “In Australia, health services are lacking cultural safety and capability when addressing Aboriginal and Torres Strait Islander people’s needs. The ongoing health gap between Aboriginal and Torres Strait Islander people and other Australians reflects the need for Australian health services to take these recommendations seriously in order to address this inequity.”
Policy makers in our healthcare systems could start by re-wording the stigmatising terms used to define leave events from healthcare services across all states and territories within Australia.
Improving healthcare providers’ understanding of power imbalances and building a more culturally capable workforce would reduce experiences of racism and stigmatisation. These actions are essential in order to decrease the number of leave events from health services and move towards improving health outcomes for Aboriginal and Torres Strait Islander people.
Dr Julieann Coombes (pictured L) is a Gumbaynggirr woman with connections to Gamilaraay country where she grew up. Julieann is a Senior Research Fellow for Guunu-maana (Heal), Aboriginal and Torres Strait Islander Health Program at The George Institute for Global Health and has extensive experience in social and cultural determinants of health research, Indigenous methodologies and applies decolonising methods to all her research projects. Julieann has a commitment to ensure that all research with Aboriginal and Torres Strait Islander people is conducted in an ethical correct way and research integrity should be underpinned by equity, transparency and self-determination. Julieann previously worked as a Registered Practice Nurse with extensive involvement in Aboriginal and Torres Strait Islander health and has lived and worked on the NSW Central Coast for the last 30 years. Julieann leads multiple large research grants to implement culturally safe health systems changes and to centre Aboriginal and Torres Strait Islander voices in directing decision making processes. These programs aim to enhance health outcomes for Aboriginal and Torres Strait Islander people and are building evidence to inform the design and implementation of healthcare strategies led in partnership Aboriginal with communities and people.
Keziah Bennett-Brook (pictured R) is a Torres Strait Islander woman, born and raised on Dharawal Country and Program Head of Guunu-maana (Heal) Aboriginal and Torres Strait Islander Health Program at The George Institute for Global Health. Keziah is a member of the Australasian Injury Prevention Network Executive and Indigenous Committee, as well as Board Member of Hepatitis NSW. Keziah chairs The George Institute’s Research Committee for Aboriginal and Torres Strait Islander Health since 2017 and leads the development and implementation of Aboriginal and Torres Strait Islander health strategy and policy, stakeholder partnerships and research coordination in a global research institute. Keziah’s expertise includes social and cultural determinants of health, Indigenous methodologies, knowledge translation and impact that privilege Indigenous knowledges, and applying decolonising methods to organisational change. Keziah leads implementation of strategic organisational activities to increase cultural safety and capability within global health research.
See Croakey’s archive of articles on cultural safety and healthcare
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